Ghana

November 2011 Posts

So I think I am finally starting to settle
in. I have gradually slowed my pace, and modified my expectations
about the realistic rate of change, and as a result I no longer
feel like a slightly irate Scottish woman on a mission to assault
the Pantang Medical Assistants with knowledge and better working
practices. We have had 4 new MAs arrive at Pantang hospital, fresh
from a new mental health teaching programme called “the Kintampo
Project” - this is an excellent collaboration between UK
psychiatric staff at Hampshire Partnership NHS foundation Trust and
Ghanaian ministry of Health. It is a rural health college, which is
training Medical Assistants in Psychiatry and Community Mental
Health Officers.

The aim is ultimately to produce a self-sustaining new
generation of specialist mental health workers that can start to
bridge the considerable gap between supply and demand for mental
health expertise in Ghana, in particular, allowing Ghanaians in the
more rural and remote areas of the country to access care. The new
MAs at Pantang are coming to the end of the first 2 year run of the
Kintampo programme and so far I have been hugely impressed by their
knowledge and drive...

It has become increasingly apparent to me over these last 5
weeks what a difficult job the MAs do here. With only a brief
additional training (at least before the Kintampo project began)
they are expected to assess, diagnose and manage the full gamut of
psychiatric diagnosis, from the cradle to the grave; there are no
specialties such as Child Psychiatry or Psychiatry of Learning
Disability or Older Adult psychiatry in Ghana… just plain old,
catch-all “Psychiatry”. And in addition, the MAs are also
confronted with many problems that we as psychiatrists in the UK
would swiftly re-dispatch towards Neurology such as epilepsy,
headaches and even stroke rehabilitation (unfortunately there are
even fewer Neurologists than Psychiatrists in Ghana, I am told).
And that is without mentioning the prevalence of physical morbidity
- the Accra MAs were late for my tutorial last week because there
had been an outbreak of Cholera on the psychiatric wards which they
were trying to treat and contain.

I am not ashamed to admit that there have many times since I
have been working here that I have felt far, far out of my clinical
comfort zone, and this is with 5 years at medical school and 8
years of full-time psychiatric training, with all the supervision
and intensive teaching that entails. Of course, the MAs are
supposed to be able to access medical support and supervision to
help them along, but in reality, with the work pressure that all
the medical and nursing staff are under here, just in terms of
volume, this is not always possible. So, like Ghanaians do with a
lot of their health issues, the MAs just…manage.

Their obvious strengths are in their familiarity with the many
nuances of West African culture, their unflappable flexibility and
resourcefulness in the face daily novel clinical challenges, and
their ability to assess and process a volume of patients that we as
clinical staff in the UK would possibly baulk at: would you fancy
seeing over ten new patients at outpatients each day, on top of
your reviews? Me neither. They are also in a brilliant position to
educate the population about the causes and treatments for mental
disorder, helping Ghanaians to integrate a biopsychosocial model in
with the more traditional concepts of “spiritual causes” for mental
disorder. But inevitably, the necessity of speedy assessments
affects the quality and depth of the history taking and mental
state examination. And similarly, without an arsenal of paramedical
support services on hand, such as the OTs, psychologists, CPNs and
social workers that we sometimes can take for granted, the desire
to be able to “offer something” quickly to the patient often plays
out in the issue of a prescription. Interestingly and unexpectedly,
one of my main challenges here has been to try and get the MAs to
think more systematically about the possibility of NOT prescribing.
Possibly this is also a cultural issue- I have noticed that
Ghanaians expect to go away with a script in their hands. It is a
definite contrast to the UK, where I think often the current trend
is for patients to be reluctant and somewhat reticent about taking
psychotropic medication (and often, quite rightly so!)

And so we continue to work together in clinics and on the wards;
we see and assess the patients, we discuss the cases, I ask them
questions about their reasoning around diagnostic or management
decisions. Sometimes we disagree, and often I find that “what I
would do if I was in the UK” is an irrelevant and pointless
proposition. For example, we see a fifteen year old boy whose
Father brings him in with what sounds like grand-mal seizures. In
the history we find that he experienced quite significant
developmental delay, not walking until the age of 2 and a half, and
not speaking until the age of five and he never managed to learn to
read or write, but he has never formally been diagnosed with a
learning disability. He has an odd, telegraphic style of speech and
it was also unclear if the seizures were new, because until
recently the boy had lived with his Mother in Nigeria and there
appeared to have been very little communication between the two
parents. His physical and neuro exam were normal. Basically he had
an undiagnosed mild-moderate learning disability of unknown
aetiology and seizures that were possibly new, but not definitely.
The family couldn’t afford any form of neuroimagaing, and only
basic blood investigations. There is no sense in searching and
searching for a possible aetiology unless there is likely to be an
effective and accessible therapeutic intervention. So we started
him on carbamazepine, gave his family some basic psycho education
about his learning disability and his seizures and arranged to see
him back for review. No neuropsychological testing, no MRI, no full
organic screen, no LD support services: just… managing.

So here I am, just past the halfway mark.
When I came out to Ghana, I think that a bit of me expected that ,
although on the surface we might have some different ways of doing
things, essentially I would realise that this was all just
superficial, cultural fluff and underneath it all, patients,
doctors, nurses...we are all the same all over the world! And
indeed, I have been struck by many interesting similarities between
the practice of Psychiatry in Ghana and the UK. Firstly, and this
probably shouldn’t have surprised me (!), major mental illnesses
such as Schizophrenia and Bipolar Affective Disorder present here
very much as they do at home.

The psychopathology is pretty much identical, although
admittedly the lag time between the appearance of symptoms and
first presentation to a mental health professional is much longer
here, as patients and families tend to exhaust all other potential
treatment avenues before consulting a medical doctor. This usually
includes some kind of “spiritual” intervention such as a
residential spell at a Christian prayer camp, or the more
traditional option of having rituals performed by a local fetish
priest (and I promise I will return to this another time).
Disorders such as mild to moderate depression and anxiety do not
tend to make it as far as a psychiatrist here like in the UK, and
perhaps this is because they are adequately dealt will by some
other non-medical means?

Another similarity is the frequent and ubiquitous co-morbid use
of cannabis in young men who present with psychotic disorders.
Other forms of substance abuse do not seem to be as visible as they
are in the west, but that might be just a matter of time.
Furthermore, just as in the UK, the patient’s family performs an
essential role in caring for and supporting the person through
illness. And probably the family’s role is even more prominent and
important here in many cases, as there is no social welfare system
to fall back on, and community psychiatric services in Ghana are
currently so spartan as to be non-existent.

It appears to be unusual for someone to live alone here, even in
the capital Accra. Patients generally stay with their families and
extended families. It is the family that brings the patient to
clinic (and sometimes the family come to clinic without the
patient), it is the family that buys their medications and
administers them (sometimes by hiding the drugs in their food
without their knowledge), and maybe inevitably, and certainly
understandably, it the family that comes along to the hospital
saying “we can’t cope any more- please admit him and give us a
rest”; of course that also happens sometimes at home. However, a
few days ago two brothers came into my outpatient clinic room,
carrying between them their floridly manic relative, wearing only
his underpants and chained at the feet and wrists with manacles.
They literally dropped him at my feet. It is at times like these,
well....you realise that you are not in Kansas (or Hampstead) any
more, Dorothy.

So the differences, the differences...where do I begin? I am not
even going to mention the discrepancies in financial and human
resource- that is obviously a given. Clearly the biggest difference
is the lack of a functioning mental health act currently in Ghana,
although as I may have mentioned previously, there is a new Bill
trying to be passed through parliament at this very moment. As a
western psychiatrist, you perhaps become habituated to the fact
that mental health act legislation, and its guiding principles,
form a solid framework for much of your daily decision making. And
that isn’t to mention the amount of time we spend at tribunals,
writing reports, reviewing sections etc. So what is it like when
that legal framework isn’t there? The other day George, one of the
MAs, asked me to come to the ward with him to review a patient. In
short, she was a lady who had previously been given a diagnosis of
delusional disorder, but due to the sustained deterioration in her
social functioning and increasingly bizarre nature of her symptoms,
we both agreed that schizophrenia was a more fitting diagnosis.

Interesting, this lady had recently been admitted to a
psychiatric hospital in Europe, under the mental health act, but
whilst on ward leave had managed to abscond and fly back home to
Ghana; her relatives had helpfully sent us some information from
this hospital admission. The lady had no insight, was delusional
and paranoid, and had lost a considerable amount of weight over the
previous few months, with an associated significant deterioration
in her self-care. She was acutely unwell, putting her health at
risk, and she was very clear that she would not cooperate with
treatment voluntarily; indeed, a concerted effort to engage her
therapeutically during her previous admission had failed. I was
clear in my mind that we should give her a chance to have a course
of treatment and I knew that this would probably involve treating
her against her will. But I found it very hard to make this
decision alone, even when I knew that I was using the same legal
framework as in the UK in my head. It felt precarious and a much
more uncomfortable decision to make solo. We ended up discussing
the case at the weekly multi-disciplinary case conference, which I
have managed to re-start. The central question that we asked those
assembled was “under what grounds can you justify detaining and
treating a patient without their explicit consent?” It took the
nurses and MAs quite a bit of prompting to come round to the themes
of active mental disorder and acute risk to self, others and/or
health. Several people suggested that lack of insight might be
reason enough.

Without a mental health act, patients do
not get a say. And I am aware that any service users reading this
might feel strongly that even with our mental health act, they
still don’t get adequately heard. But here, you can be brought to
hospital off the street as a “vagrant admission” and without any
family to advocate for you, still find yourself in hospital 15
years later because you have nowhere else to go and nobody
wondering very much why you have been in hospital for so
long.

You can be admitted to hospital on the whim
of a judge who thinks that you “might be acting a bit strangely”,
and again find yourself in a different kind of prison for an
indefinite period. If your family admit you into hospital, and then
decide that they can’t look after you any more, well, they just
need to leave a false address and phone number, and then make
themselves scarce, leaving you, the patient, with precious few
options. That is, if your family can afford to bring you the long
journey to hospital at all. So many times since I have been in
Africa, I have reflected on the NHS and the services that we are
able to provide. When I left the UK, the future of the NHS was the
topic of ongoing fierce political debate and I know that this
continues. It probably sounds like the most utterly clichéd and
corny thing that somebody could say after working in a developing
country, but maybe that is because it is true: we have literally no
idea how good we have it.

About this blog

Hello, my name is Susie Easton and I am an ST6 on the UCL/Royal
Free Hospital General Adult Psychiatry Rotation in North
London. I have just got my CCT and when I return from Ghana, I
will be moving home to Glasgow to take up my first consultant
post.

When I saw the Ghana post advertised, I thought that it looked
interesting, a bit scarey and an opportunity for a
professional and personal adventure.

This personal blog reflects Dr Easton's own views, and not
neccessarily the organisations that she is working with. However
Dr Easton is indebted to the partnership between South
West London and St Georges mental health Trust, the charity
Challenges Worldwide and the Royal College of
Psychiatrists for providing an opportunity to take part
in this excellent project. She is also very grateful to Dr
Peter Hughes for his regular and invaluable clinial
electronic supervision, Challenges Worldwide for
their excellent logistical support, and Dr Anna Dzadney the
Medical Director at Pantang hospital for making her feel so
welcome. And last but not least, she is indebted to the Ghanaian
Medical Assistants with whom she works, for helping her learn about
how mental illness in West Africa.